The Rapid Tranquillization Policy. (including the use of oral PRN medication) (Replaces Policy No. 198/Clinical)

A member of: Association of UK University Hospitals The Rapid Tranquillization Policy. (including the use of oral PRN medication) (Replaces Policy No. 198/Clinical) (The Use of Medication in the Control of Acutely Disturbed or Violent Behaviour). (This policy applies to Working Age Adult, Secure & Forensic, Specialist Women s, Older People s, Children & Young Peoples, and Learning Disability Services). POLICY NUMBER TPCL/018 RATIFYING COMMITTEE Professional Practice Forum DATE RATIFIED 01 October 2016 EQUALITY & HUMAN RIGHTS 01 March 2011 IMPACT ASSESSMENT NEXT REVIEW DATE November 2018 EXECUTIVE SPONSOR Executive Medical Director POLICY AUTHORS Jules Haste Lead Pharmacist Trudie Morgan Lead Pharmacist Jed Hewitt Chief Pharmacist (Governance) Executive Summary: When to consider using Rapid Tranquillization and the process to follow, including record keeping, monitoring and training. Consideration of advance decisions/statements. Specific risk issues. If you require this document in another format such as large print, audio or other community language please contact the Corporate Governance Team on 01903 843041 or email: policies@sussexpartnership.nhs.uk

CONTENTS Page 1. Introduction 1.1 Purpose of this Policy and Guidance Document 5 1.2 Scope of this Policy and Guidance Document 5 1.3 Definition 5 1.4 Principles 5 1.5 Equality Impact Statement 6 1.6 Training Expectations 6 2. Policy Statement 7 3. Policy and Procedural Practice 3.1 Key Priorities 7 3.2 Mental Health Act Considerations 9 3.3 Rapid Tranquillization and Seclusion 9 3.4 Overview of the Short-Term Management of Disturbed 10 / Violent Behaviour 1 4. Medication 4.1 Treatment aims 11 4.2 Prescribing 11 4.3 Choice of medication 12 4.4 High doses 14 4.5 Oral PRN medication 14 5. Administration of Medication 15 6. Monitoring the Patient and Recording 17 7. Medication Specific Risks 18 8. Discontinuation of Rapid Tranquillization 19 9. Advance Decisions and Statements 19 Algorithm 1 (RT in WAA) 20 Algorithm 2 (RT in OPMHS) 22 Algorithm 3 (RT in ChYPS) 24 Algorithm 4 (RT in LD) 26 10. Specialist advice for working outside the appropriate algorithm 28 11. Intravenous Therapy 29 12. Responsibilities 12.1 The Trust 29 12.2 Medical and Nursing Professional Leads 29 12.3 Trust Pharmacy Team 29 12.4 Ward Managers and Modern Matrons 30 12.5 Consultants 30 12.6 Individual Clinical Staff 30 13. Monitoring Compliance with the Policy 30 Page 2 of 52

14. Development, Consultation and Ratification 31 15. Dissemination and Implementation of policy 31 16. Document Control including Archive Arrangements 31 17. References 32 18. Other Trust Policies to be Cross-referenced 32 Appendix 1 Physical health monitoring and remedial measures 34 Appendix 2A/B/C MEWS form for use in RT & at risk oral PRN 35 Appendix 3 Guideline for the use of flumazenil 41 Appendix 4 - IM medication further considerations 42 Appendix 5 Monitoring Broset Violence Checklist 46 Appendix 6 Maximum BNF doses (adults & elderly) in 24 hours 48 Appendix 7 Maximum recommended doses in 24 hours for children and adolescents 49 Appendix 8 Pharmacokinetics 50 Appendix 9 Drugs known to prolong QT Interval 51 Appendix 10 Glossary of Terms 52 Page 3 of 52

1. Introduction 1 1.1 Purpose of this Policy. The purpose of this document is to provide staff working in Sussex Partnership NHS Foundation Trust wards with guidance about the use of Rapid Tranquillization (RT). It sets out the main provisions of appropriate use of RT, use of associated medication and the roles and responsibilities of staff. 1.2 Scope of this Policy. This document applies to all qualified medical and nursing staff (and non-medical prescribers) involved in the prescribing and/or administration of medication for RT. This includes staff employed by the Trust and also those healthcare staff who are either seconded or contracted to the Trust. The document covers the treatment of inpatients in working age adult services, secure and forensic services, specialist women s services, older people s services and children and young people s services. Currently this document does not cover patients with a primary diagnosis of substance misuse, behaviour difficulties in Alzheimer s disease or delirium. 1.3 Definition. Rapid Tranquillization is the use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed. Although oral medication is not considered to be Rapid Tranquillization (NICE NG10) due to the potential agitated state it is considered good practice to closely monitor the patient following administration of oral as required medication. 1.4 Principles. RT is to calm a patient who is exhibiting acutely disturbed or violent behaviour. It is intended to reduce the risk of harm to the patient and also to other patients and members of staff by reducing agitation and aggression. The optimal delivery of RT will allow further psychiatric evaluation to take place and will not compromise patient comprehension or their ability to respond to spoken messages or instruction. RT should only be considered once de-escalation and other strategies have failed to calm the patient. (See section 3.4). The intervention (along with physical intervention and seclusion) should be considered a management strategy and not be regarded as a primary treatment technique. When determining which intervention to employ, clinical need, the safety of service users and others and, where possible, any Advance Decisions or Advance Statements should always be taken into account. The intervention selected must be a reasonable and proportionate response to the risk posed by the patient at that particular time. The reasons for using RT (and any other intervention) must always be explained to the patient at the earliest opportunity. Page 4 of 52

1.5 Equality Impact Assessment. (Undertaken in March 2011). All patients covered by this policy, regardless of their race, gender, gender identity, sexuality, religion, spiritual beliefs or disability, will be treated equally within the principles of the policy and with equal dignity and respect. 1.6 Training Expectations. 1.6.1 An understanding of the Rapid Tranquillization Policy is essential for all qualified staff that may be called upon to prescribe and/or administer medication in response to situations described in the Violence and Aggression (PMVA) the Prevention and Management of Policy. These two documents should be read in conjunction. Staff must also be familiar with the Resuscitation and Anaphylaxis Policy and the Observation Policy. -. It is considered essential that all qualified medical and nursing staff working in inpatient units be trained in the use of RT, (based on the treatment algorithm most suitable for their unit), and that this training is undertaken every two years. The responsibility to ensure adequate training is undertaken lies with ward managers and modern matrons (for nursing staff) and with consultants and local tutors (for medical staff). 1.6.2 The training requirement for RT varies according to whether the member of staff is a doctor (or non-medical prescriber) or a nurse. All new medical staff should successfully complete the specific My Learning module training in RT as part of their induction training, whether working in community or hospital if they are expected to cover inpatient units as part of their on-call duties. Nursing staff working on wards in substantive or bank posts will undertake RT training as a specific My Learning module and receive a brief update as part of their Medicines Management Update day. Ward managers and matrons will ensure that each member of their nursing staff has undertaken and successfully completed the e-learning module. Newly qualified staff will also be expected to pass the RT competencies as outlined in the Trust Preceptorship Policy. Wherever possible, RT training will be accessed within three months of commencing an inpatient role. Ward managers and modern matrons will be aware of their staff that have completed and passed this training and the Trust central training department must keep records of all staff completing the training. Training will cover the properties of benzodiazepines, the benzodiazepine antagonist flumazenil, antipsychotics, antimuscarinics and antihistamines, their doses and how they are used in the RT process. It will also cover associated risks, including side effects such as cardio-respiratory effects in response to acute administration of the drugs, particularly when the patient is highly aroused and may have been misusing drugs, is dehydrated or is possibly physically ill. All staff involved in RT also need to be adequately trained in the maintenance of patient s airways, cardio-pulmonary resuscitation (CPR), the use of defibrillators and the use of pulse oximeters. Page 5 of 52

1.6.3 The RT e-learning module can be accessed via the Trust Intranet and contains all the necessary information in the use of RT. All staff involved in RT should undertake this e-learning module every 3 years. http://susie.sussexpartnership.nhs.uk/education-training/elearning 1.6.4 In addition, the pharmacy team delivers an update and signposting to the e-learning module in their Medicines Management Essential Training Day for Qualified Nurses. This includes advising nurses of any recent significant changes to policy or practice that have occurred. 2. Policy Statement. The Trust recognises that, at times, patients in our care may respond to their feelings of aggression or extreme agitation. Therefore, it is important that Trust staff are appropriately trained and supported in order to ensure the safe administration of parenteral medication and the monitoring of its effects on the patient. When a decision needs to be made on behalf of a patient, staff will make this decision in accordance with the principles of best interest and least restrictive option. (See also section 3.2 for Mental Health Act considerations). 3. Policy and Procedural Practice. 3.1 Key Priorities. 3.1.1 Resuscitation facilities must be available within 3 minutes in all healthcare settings where RT might be used. Equipment available must include an automatic external defibrillator, a bag valve mask, oxygen and suction equipment. All equipment must be properly maintained and checked on a weekly basis and a record maintained. 3.1.2 All prescribers and staff involved in RT must be familiar with and have access to the Trust Resuscitation Policy. 3.1.3 All staff involved in an incident requiring the use of parenteral RT (or physical intervention) should be aware of the potential for damage to the patient / professional relationship and ensure that everything possible is done to avoid its impact. 3.1.4 Any incident requiring RT (or physical intervention or seclusion) must be contemporaneously recorded. All appropriate staff should be trained to ensure that they are aware of how to correctly record any incident using the appropriate on-line documentation http://rx2as012.spdom.local/safeguard/index.aspx?sid=%20 3.1.5 Where possible a post-incident review should take place as soon as possible and within 72 hours of an incident ending. This review should be led by the Ward Manager (or nominated deputy) and address the following factors: What happened during the incident? What were the trigger factors? Each person s role in the incident. Page 6 of 52

Their feelings at the time of the incident, at the review and how they may feel in the near future. What can be done to address their concerns? NICE states Formal external post-incident review should take place incorporating The service user experience monitoring unit or equivalent service user group should undertake a formal external post-incident review as soon as possible and no later than 72 hours after the incident. The unit or group should ensure that the formal external post-incident review: is led by a service user and includes staff from outside the ward where the incident took place, all of whom are trained to undertake investigations that aim to help staff learn and improve rather than assign blame uses the information recorded in the immediate post-incident debrief and the service user's notes relating to the incident includes interviews with staff, the service user involved and any witnesses if further information is needed o evaluate the physical and emotional impact on everyone involved, including witnesses o help service users and staff to identify what led to the incident and what could have been done differently o determine whether alternatives, including less restrictive interventions, were discussed o determine whether service barriers or constraints make it difficult to avoid the same course of actions in future o recommend changes to the service's philosophy, policies, care environment treatment approaches, staff education and training, if appropriate o avoid a similar incident happening in future, if possible. 3.1.6 All staff involved in RT need to be aware of the legal framework that authorises this intervention. The intervention should be in line with the guidance contained within the current Mental Health Act Code of practice, (and the Mental Capacity Act), and any departure from that guidance should be clearly recorded and justified as being in the best interests of the patient. (See section 3.2) 3.1.7 Specific to ChYPS. All patients must be informed that medication is to be given and given the opportunity at any stage to accept oral medication voluntarily. In children/adolescents who are not Gillick competent, parent(s)/carer(s) should be informed of the situation and consent sought for treatment, in advance if at all possible. It is good practice to inform the child/adolescent and parent(s)/carer(s). Consent forms are available from the Trust website. http://www.sussexpartnership.nhs.uk/charts-and-forms Page 7 of 52

3.1.8 Specific to LDS. All patients must be informed (in a way that best facilitates their understanding) that medication is to be given and given the opportunity to accept oral medication. Wherever possible the client and carers should be informed about different options and the carers opinions recorded on the forms available via the trust website. http://www.sussexpartnership.nhs.uk/node/2632/attachment 3.2 Mental Health Act Considerations 12 3.2.1 Patients detained under the treatment sections of the Mental Health Act are subject to Consent to Treatment provisions of Part 4 of the Act. If a patient has been detained for more than 3 months their consent, or authorisation for treatment from a Second Opinion Appointed Doctor (SOAD), is required under Section 58(3) including the completion of statutory forms T2 or T3 before treatment can be given, unless the patient meets the criteria for treatment under Section 62 urgent treatment. 3.2.2 If the patient has been subject to the Act for less than 3 months, treatment can be given under the provision of Section 63. 3.2.3 All information relevant to MHA status must be fully documented in the clinical record. 3.2.4 The patient s legal status should be reviewed whenever parenteral medication is considered. The enforced administration of medication by injection to an informal patient may necessitate use of the Mental Health Act. If treatment is to continue against the patient s wishes then a MHA assessment must be undertaken to ensure continued administration is lawful. 3.3 Rapid Tranquillization and Seclusion A combination of these two interventions is not absolutely contra-indicated providing that the following points are established: If the patient is secluded, potential complications in response to RT are particularly serious and must be given full consideration. The patient must be monitored by within eyesight observation by a trained member of staff. (See also the Observation Policy and the Seclusion and Long Term Segregation Policy). Undertake a risk assessment and consider ending the seclusion when RT has taken effect. Page 8 of 52

Continuous risk reassessment and use of de-escalation techniques Rapid Tranquillization Policy 3.4 OVERVIEW OF THE SHORT-TERM MANAGEMENT OF DISTURBED / VIOLENT BEHAVIOUR 2 PREDICTION Risk assessment Necessary & Lawful Searches Mental Health Presentation Behavioural Presentation Other incidents (especially if escalating). PREVENTION De-escalation techniques Observation INTERVENTIONS FOR CONTINUED MANAGEMENT Consider, in addition to above, one or more of the following: Rapid Tranquillization (RT) Use to avoid prolonged physical intervention Medication is required to calm a psychotic or non-psychotic behaviourally disturbed service user When service user has taken previous medication Seclusion Used to avoid prolonged physical intervention CONTRA-INDICATED AS AN INTERVENTION Should be terminated when rapid tranquillization, if given, has taken effect When other interventions not yet explored Physical Intervention Better if service user responds quickly Can be used to facilitate administration of RT and/or to enable RT to take effect Prolonged physical intervention POST-INCIDENT REVIEW Page 9 of 52

4. Medication 4.1. Treatment aims 3 To reduce suffering for the patient: psychological or physical (through selfharm or accidents). To reduce risk of harm to others by maintaining a safe environment. To do no harm (by prescribing safe regimes and monitoring physical health). 4.2. Prescribing 4.2.1 Only a Trust prescriber should prescribe medication for RT. The reason for prescribing should be documented in the clinical record, including the treatment plan. 4.2.2 Do not prescribe RT medication routinely or automatically on admission on the prn section of the drug chart. NICE guidance states that RT should initially only be a single dose 4.2.3 Only when RT continues to be required should it be prescribed on the prn section of the chart including indication, maximum dose, interval and maximum daily dose. This should be reviewed at least once weekly and if not used within the last week, consider stopping it. 4.2.4 If more than one medication is prescribed, the care plan should include the preferred order of administration of medicines and time interval between the medicines. 4.2.5 When deciding which medication to use take into account any contraindications, warning or precautions required 5. the service user's preferences or advance statements and decisions pre-existing physical health problems or pregnancy possible intoxication(alcohol or psychoactive drugs) previous response to these medications, including adverse effects potential for interactions with other medications the total daily dose of medications prescribed and administered. 4.2.6 Full details of contra-indications, special warnings and precautions for all medicines can be found on http://www.medicines.org.uk/emc Page 10 of 52

4.3 Choice of medication 1 Based on the review of rapid tranquillization 1, the evidence suggested that two management strategies may have benefits that outweigh the risks of harm: an IM benzodiazepine (lorazepam) used alone and the combination of IM haloperidol plus an IM antihistamine (promethazine). When IM haloperidol is combined with IM promethazine there is some suggestion that risk of movement-related side effects may be reduced. In contrast, the combination of an IM benzodiazepine plus IM haloperidol does not appear to be more effective than an IM benzodiazepine used alone. While IM haloperidol used alone is more effective than placebo, it clearly carries greater risk of extrapyramidal and other side effects when compared with placebo or an IM benzodiazepine. There was insufficient evidence to make a judgement about the relative risk/benefits of other antipsychotic drugs. NICE guideline NG10 does not include the use of olanzapine IM injection as there is no UK product available, having been withdrawn from the market. EU-licensed products are available and so it has been included in this policy document. Promethazine intramuscular injection is not licensed for the acute management of disturbed/violent behaviour. However, there are some studies (TREC trials) to support its use in this therapy area. Promethazine has anticholinergic side effects such as dry mouth, blurred vision, urinary retention and constipation. Cognition can also be impaired particularly in patients with a diagnosis of dementia. It should therefore be used with caution in this patient group. Particular care should also be taken in those patients with a Learning Disability. 4.3.1 RT refers to the use of medication by the parental route (usually intramuscular or, exceptionally intravenous). It should only be used if oral administration is not possible or appropriate, or if urgent sedation with medication is needed. (See algorithms 1, 2, 3 and 4). 4.3.2 If an advance decision or advance statement has been completed this should be considered in the first instance. If for clinical reasons an advance decision or statement is not followed, the doctor should fully record these reasons in the patient s clinical record. Patient preference for medication should also be considered at this stage. 4.3.3 It should be noted that antipsychotics in RT are not used for their antipsychotic action as onset of the antipsychotic effect can take several weeks. 4.3.3.1 If there is insufficient information to guide the choice of medication for rapid tranquillization, or the service user has not taken antipsychotic medication before, use intramuscular lorazepam 4.3.3.2 Where there are no known contraindications to the use of antipsychotic medication use IM haloperidol combined with IM promethazine. Page 11 of 52

4.3.3.3 If there is evidence of cardiovascular disease, including a prolonged QT interval, avoid intramuscular haloperidol, use intramuscular lorazepam. 4.3.3.4 Where no electrocardiogram has been carried out, avoid intramuscular haloperidol, use IM lorazepam or IM olanzapine if an antipsychotic is deemed necessary. If haloperidol is used when no ECG is available the prescriber should consider the risks and benefits of using this treatment and be able to justify their prescribing decision as this would be considered an off-label use. 4.3.3.5 If there is a partial response to intramuscular haloperidol combined with intramuscular promethazine, consider a further dose of this combination. 4.3.3.6 If there is a partial response to intramuscular lorazepam consider a further dose. 4.3.3.7 If there is a partial response to intramuscular olanzapine, consider a further dose (note: 2 hour dose interval). 4.3.3.8 If there is no response to intramuscular lorazepam consider intramuscular haloperidol combined with intramuscular promethazine. 4.3.3.9 If there is no response to intramuscular haloperidol combined with intramuscular promethazine, consider intramuscular lorazepam if this hasn't been used already during this episode. IM olanzapine should also be considered as per section 4.3.3.4 above. 4.3.3.10 If intramuscular lorazepam has already been used, seek an urgent second opinion. 4.3.3.11 When prescribing medication for use in rapid tranquillization, write the initial prescription as a single dose, and do not repeat it until the effect of the initial dose has been reviewed. 4.3.3.12 If more than one medication is prescribed for the same indication, the care plan should include the preferred order of administration of medicines and time interval between the medicines. If two medications are intended to be given at the same time this should be clearly stated. 4.3.3.13 It is important to note that medications within the CHYPS algorithm (see algorithm 3) include unlicensed use of medications: Olanzapine (oral and IM) is unlicensed for use in patients aged less than 18 years. Lorazepam (oral and IM) is unlicensed for use in patients aged less than 12 years. Page 12 of 52

4.4 High doses. (See appendix 6). In certain circumstances, current British National Formulary (BNF) doses and limits, and the manufacturers Summary of Product Characteristics (SmPC), may be knowingly exceeded e.g. in the case of lorazepam. This decision should not be taken lightly or the risks underestimated, and a risk-benefit analysis should be recorded in the clinical record and a rationale in the care plan. Where the risk-benefit is unclear, consideration should be given to seeking advice from clinicians who are not directly involved in the care of the patient. If current BNF or SPC doses are exceeded it is particularly important to undertake frequent and intensive monitoring every 15minutes of a calmed patient. Particular attention must be given to regular checks of the airway, level of consciousness, pulse, blood pressure, respiratory effort, temperature and hydration. If the patient is not amenable to monitoring of their vital signs an observation record should be made of their level of consciousness, physical activity, mobility, skin colour and breathing. 4.5 Use of oral PRN medication Rapid Tranquillization is the use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral administration is not possible or appropriate, or if urgent sedation with medication is needed. Although oral medication is not considered to be Rapid Tranquillization (NICE NG10) due to the potential agitated state it is considered good practice to closely monitor the patient following administration of oral as required medication. 4.5.1 Only a Trust prescriber should prescribe PRN medication. The reason for prescribing should be documented in the clinical record, including the treatment plan. 4.5.2 Do not prescribe PRN medication routinely or automatically on admission on the prn section of the drug chart and initially (where needed) only prescribe a time limited prescription to cover 96 hours. 4.5.3 Only when PRN continues to be required should it be prescribed on the prn section of the chart including indication, maximum dose, interval and maximum daily dose. This should be reviewed at least once weekly and if not used within the last 2 weeks, consider stopping it. Note also that Trust pharmacists have the authority to cancel these prescriptions if they remain unused for 14 days. 4.5.4 Oral PRN medication should be offered first line. 4.5.5 If an advance decision or advance statement has been completed this should be considered in the first instance. If for clinical reasons an advance decision or statement is not followed, the doctor should fully record these reasons in the patient s clinical record. Patient preference for medication should also be considered at this stage. 4.5.6 It should be noted that PRN antipsychotics are not used for their antipsychotic action as onset of the antipsychotic effect can take several weeks. Page 13 of 52

4.5.7 If more than one medication is prescribed, the care plan should include the preferred order of administration of medicines and time interval between the medicines. 4.5.8 If two medications are intended to be given at the same time this should be clearly stated. 4.5.9 When deciding which medication to use take into account any contraindications, special warnings or precautions required 5. Also consider: the service user's preferences or advance statements and decisions pre-existing physical health problems or pregnancy possible intoxication (alcohol or psychoactive drugs) previous response to these medications, including adverse effects potential for interactions with other medications total daily dose of medications prescribed and administered. 4.5.10 Full details of contra-indications, special warnings and precautions for all medicines can be found on http://www.medicines.org.uk/emc 4.5.11 If the patient is considered to be at risk ensure that specific, enhanced physical health monitoring is undertaken using the physical observation chart for patients at risk administered oral PRN medication for aggression or severe agitation. (See Appendix 2c). Monitoring these at risk patients must continue for a minimum of four hours. Those patients not considered at risk do not require enhanced monitoring. 5 Administration of medication 5.1 Choosing an appropriate site. Most of the short acting intramuscular (IM) injections used in RT state the injection can be given intramuscularly (lorazepam, olanzapine and haloperidol) or administer by deep intramuscular injection (promethazine). They do not state specific intramuscular sites hence any of the safe sites listed below can be used. See individuals SPC for more information (www.medicines.org.uk) Whilst it is recognised that intramuscular (IM) injections may need to be administered to a resisting / struggling patient, extreme care must be taken with the injection as in these cases there is a greater risk of hitting a vein and the drug being given intravenously (IV). Page 14 of 52

5.2 Prone Position. Administration of IM injections to patients held in a prone position is not banned. If it is necessary to use the prone position for this purpose it can be done by people who are trained in the PMVA physical skills to use it. It should only be used for the shortest possible time whilst maintaining the appropriate physical health monitoring checks. Registered Nurses should ensure that records of these occasions are completed thoroughly and when completing the Safeguard incident form it is essential that you indicate the period of time that the person was in the prone position. 5.3 Safe sites of IM Injection. Dorsogluteal Muscle (buttocks): Expose one side of the buttocks. With an alcohol wipe draw a line from the top of the crack between the buttocks to the side of the body. Find the middle of that line and go up 3 inches. From that point, draw another line down and across the first line, ending about halfway down the buttock. You should have drawn a cross. In the upper outer square you will feel a curved bone. The injection will go in the upper outer square below the curved bone. Deltoid Muscle (Upper arm muscle): Completely expose the upper arm. You will give the injection in the center of an upside down triangle. Feel for the bone that goes across the top of the upper arm. This bone is called the acromion process. The bottom of it will form the base of the triangle. The point of the triangle is directly below the middle of the base at about the level of the armpit. The correct area to give an injection is in the center of the triangle, 1 to 2 inches below the acromion process. This site should not be used if the person is very thin or the muscle is very small. Vastus Lateralis Muscle (Thigh): Look at the thigh and divide it into 3 equal parts. The middle third is where the injection will go. The thigh is a good place to give an injection because it is easy to see. Ventrogluteal Muscle (Hip): Have the person getting the injection lie on his or her side. To find the correct location, place the heel of your hand on the upper, outer part of the thigh where it meets the buttocks. Point your thumb at the groin and your fingers toward the person's head. Form a V with your fingers by separating your first finger from the other 3 fingers. You will feel the edge of a bone along the tips of your little and ring fingers. The place to give the injection is in the middle of the V. The hip is a good place for an injection for adults. 5.4 Recommended maximum volumes of fluid for each muscle group. Deltoid 2mL Dorsogluteal 4mL Ventrogluteal 2.5 to 4mL 5.5 See Appendix 6 for drug specific details of administration Page 15 of 52

5.6 Any medication administered must be clearly and fully documented on the Drug Prescription and Administration Record Chart. The patient s response to the medication must be clearly and fully documented in their clinical record with clear reference made to the use of medication for Rapid Tranquillization purposes 5.7 Medicines for injection must not be mixed in the same syringe. 5.8 Nursing and medical staff should always have a short feedback session following emergency restraint and RT. 5.9 Following RT, discussion should always be held with the patient and their views sought on the episode. This should be documented in their clinical notes and they should be offered the opportunity to write their own account. 1 Consideration must be given to providing appropriate assistance to those patients who do not use English as their first language and those who may have other communication difficulties due to age or disability. 6 Monitoring the patient and recording. 6.1. If possible, baseline measurements of the following should be recorded before any parenteral drug administration: - Temperature - Pulse and respiration rate - Blood pressure - Level of hydration - Level of consciousness If these cannot be done, reference should be made to any recently obtained baseline measurements that are available. In such circumstances there should be a record made of what can be observed, for example, evidence of injuries, level of consciousness, pallor, breathing and mobility. If no physical observations can be made a record should still be made in the clinical notes of the reason for this and the fact that the patient was still monitored. 6.2 Where possible, (and where it is safe to do so), temperature, pulse, respiration rate and blood pressure, level of hydration and level of consciousness should be recorded at least every 30 minutes for a minimum of 2 hours or until no further concerns about physical health following the parenteral administration of any drug. Monitor every 15 minutes if the BNF maximum dose has been exceeded or the service user: Appears to be asleep or sedated Has taken illicit drugs or alcohol Has a pre-existing physical health problem. Has experienced any harm as a result of any restrictive intervention. Page 16 of 52

6.3 The record of TPR and blood pressure must be made on RT MEWS chart (Appendix 2A/B). 6.4 All patients administered RT must be subject to either intermittent enhanced, within arm s length enhanced or within eyesight enhanced observation, according to assessed clinical need. Assessment must take into consideration the patients physical health status as well as their current psychiatric presentation and the assessment and rationale for the level of observation must be clearly recorded in the clinical notes. 6.5 Observations must continue for at least two hours and until the patient is assessed as being calm and any changes to physical health parameters have returned to normal. The level of observation required should also be reassessed and any change recorded throughout the episode. 6.6 In addition, staff should closely monitor for signs of extrapyramidal side effects (and in particular, laryngeal dystonia) in response to the administration of antipsychotic medication, by any route. 6.7 Where the patient is unconscious or asleep, the same monitoring should take place so far as is possible, and pulse-oximetry should also be used, where it is practical to do so. 6.8 If the patient refuses / declines monitoring R for refusal should be endorsed on the chart and as a minimum respiration rate should be monitored and recorded every 30 minutes. (or 15 minutes as per 6.2) This would include patients held in seclusion. 6.9 Where possible, and where facilities exist, ECG and haematological monitoring are strongly recommended whenever antipsychotics are administered and especially where high doses or parenteral route are be used. High stress levels, restraint, agitation, and hypokalaemia all place the patient at high risk of developing cardiac arrhythmias. The RT event should always be fully recorded in the clinical notes. 6.10 ECG s need to be less than 3 months old to be considered appropriate for use assuming there have been no significant cardiac changes since the ECG was obtained. 7 Medication Specific Risks There are specific risks with different classes of medication and these risks may be compounded when medication is used in combination. Close monitoring of the patient is essential. Benzodiazepines Loss of consciousness, respiratory depression or arrest, cardiovascular collapse (particularly in patients already receiving clozapine), disinhibition 4. Page 17 of 52

Antipsychotics Antihistamines Loss of consciousness, cardiovascular / respiratory complications and collapse, seizures, akathisia, dystonia, dyskinesia, neuroleptic malignant syndrome, excessive sedation. Excessive sedation, painful injection and additional antimuscarinic effects. Promethazine can also cause EPSE. However, when given with haloperidol these effects were less than those seen with haloperidol alone. (TREC trials). 8 Discontinuation of Rapid Tranquillization RT should be discontinued at the point of response. Thereafter, the patient must continue to be closely monitored, and future medication (both regular and as required) should be reviewed. 9 Advance Decision and Advance Statements Once a patient has received RT, consideration should be given to drawing up an advance decision or statement for future occasions. This should take into account the response to medication and the patient s experience of the event. (See section 3.1.6). Page 18 of 52

Algorithm 1 Rapid Tranquillization of the Acutely Disturbed / Violent Patient - Working Age Adult PRIOR TO RAPID TRANQUILLIZATION Try non-pharmacological measures - De-escalation, distraction, etc. Always offer oral medication before IM. If patient refuses or oral is ineffective then consider IM RT. o Lorazepam 1-2mg o OR haloperidol 5mg with promethazine 25-50mg o OR olanzapine 10mg Allow at least one hour for oral medication to work. Consult any Advance decision/statements KNOWN PATIENT MONITORING Ensure baseline measurements are recorded where possible: Record pulse, blood pressure, respiration rate, temperature, level of hydration and level of consciousness EVERY 30 minutes (15 minutes if extra risk - see below) for at least 2 hours EXTRA RISKS INCLUDE If the BNF maximum dose has been exceeded Or the service user: o appears to be asleep or sedated o has taken illicit drugs or alcohol o has a pre-existing physical health problem o has experienced any harm as a result of any restrictive intervention. UNKNOWN OR NEUROLEPTIC NAÏVE PATIENT No cardiac disease (ECG carried out) Haloperidol 5mg I/M and Promethazine 25mg-50mg I/M (a.1) WAIT 30 minutes Cardiac disease or unknown (No ECG) Lorazepam 1-2mg I/M Or Olanzapine 5 10mg IM WAIT 30 minutes Partial response REPEAT Lorazepam 1-2mg I/M Lorazepam 1-2mg (a 1.) I/M WAIT 30 minutes No response Partial response No response Partial response No response REPEAT Haloperidol 5mg I/M and Promethazine 25-50mg I/M SWITCH Lorazepam 1-2mg I/M Or (WAIT 1hr) (f) Olanzapine 5 10mg IM REPEAT Lorazepam 1-2mg I/M Or (WAIT 2 Hours) (e) Olanzapine 5 10mg IM SWITCH Lorazepam 1-2mg I/M Or Olanzapine 5 10mg I/M (WAIT 1 hour) (f) No cardiac disease (ECG carried out) Haloperidol 5mg I/M and Promethazine 25-50mg I/M Cardiac disease or unknown (No ECG) Olanzapine 5 10mg IM (WAIT 1 hour) (f) Page 19 of 52

Notes: a. Evidence i. The best evidence for benefit over risk of harm is for IM lorazepam used alone and the combination of IM haloperidol plus an IM promethazine. ii. When IM haloperidol is combined with IM promethazine there is some suggestion that risk of movement-related side effects may be reduced. iii. In contrast, the combination of an IM benzodiazepine plus IM haloperidol does not appear to be more effective than an IM benzodiazepine used alone. iv. While IM haloperidol used alone is more effective than placebo, it clearly carries greater risk of extrapyramidal and other side effects when compared with placebo or an IM benzodiazepine. b. Choice depends on current treatment. i. If patient is established on antipsychotics, lorazepam may be used alone. ii. If the patient uses street drugs or already receives regular benzodiazepines, an antipsychotic may be used alone. c. Ensure procyclidine injection is available. Antipsychotics may cause acute dystonic reaction. d. Ensure flumazenil injection is available to reverse effects of lorazepam injection. e. The maximum dose of olanzapine is 20mg/24 hours by any (combined) route(s) this should not be exceeded without obtaining specialist advice and not more than 3 I/M doses may be given in any 24-hour period. Wait 2 hours between doses. f. Intramuscular olanzapine, intramuscular lorazepam or intramuscular promethazine must not be administered within 1 hour of each other. g. Olanzapine IM needs to be diluted before administration in 2.1ml water for injection. It is stable for up to 1 hour after reconstitution. The following table provides injection volumes for delivering various doses of olanzapine: Dose (mg) Volume of Injection (ml) 5.0 1.0 7.5 1.5 10 2.0 h. Lorazepam should be mixed 1:1 with water for injection before injecting. The following table provides injection volumes for delivering various doses of lorazepam once diluted. Dose of lorazepam Volume of undiluted Volume of WFI Required lorazepam (4mg/mL) 0.5 0.125mL 0.125mL 1.0 0.25mL 0.25mL 2.0 0.5mL 0.5mL i. The maximum daily dose of haloperidol is either 20mg orally or 12mg by intramuscular injection. Maximum doses will need to be adjusted if a combination of both routes is used. The bioavailable equivalence of haloperidol being approximately 10mg oral: 6mg intramuscular. j. The recommended dose of promethazine is 25mg to 50mg (including adolescents aged 16 years and over). The lower dose should normally be used initially and titrated upwards according to response if necessary. Repeat doses should not be considered within an hour of a previous dose and a maximum dose of 100mg in 24 hours should not be exceeded. Doses of up to 150mg have been used but this would be unlicensed use. Page 20 of 52

Algorithm 2 Rapid Tranquillization of the Acutely Disturbed / Violent Patient Patient Aged Over 65 years - (not for routine management of delirium) PRIOR TO RAPID TRANQUILLIZATION Try non-pharmacological measures - De-escalation, distraction, etc. Always offer oral medication before IM. If patient refuses or oral is ineffective then consider I/M RT. o Lorazepam 0.5-1mg o OR haloperidol 0.5 2.5mg with promethazine 12.5-25mg o OR olanzapine 2.5-5mg Allow at least one hour for oral medication to work. Consult any Advance decision/statements KNOWN PATIENT MONITORING Ensure baseline measurements are recorded where possible: Record pulse, blood pressure, respiration rate, temperature, level of hydration and level of consciousness EVERY 30 minutes (15 minutes if extra risk - see below) for at least 2 hours EXTRA RISKS INCLUDE If the BNF maximum dose has been exceeded Or the service user: o appears to be asleep or sedated o has taken illicit drugs or alcohol o has a pre-existing physical health problem o has experienced any harm as a result of any restrictive intervention. UNKNOWN OR NEUROLEPTIC NAÏVE PATIENT No cardiac disease (ECG carried out) Haloperidol 0.5 2.5mg I/M and Promethazine 12.5-25mg I/M (a.1) WAIT 1 hour DO NOT USE Olanzapine in dementia or Haloperidol for Lewy Body Dementia Cardiac disease or unknown (No ECG) Lorazepam 0.5-1mg I/M Or Olanzapine 2.5 5mg IM WAIT 1 hour Partial response REPEAT Lorazepam 0.5-1mg I/M Lorazepam 0.5-1mg (a 1.) I/M WAIT 1 hour No response Partial response No response Partial response No response REPEAT Haloperidol 0.5 2.5mg I/M and Promethazine 12.5-25mg I/M ) SWITCH Lorazepam 0.5-1mg I/M Or Olanzapine 2.5 5mg IM REPEAT Lorazepam 0.5-1mg I/M Or (WAIT 2 hours) Olanzapine 2.5 5mg IM SWITCH Lorazepam 0.5-1mg I/M Or Olanzapine 2.5 5mg IM No cardiac disease (ECG carried out) SWITCH Haloperidol 0.5 2.5mg I/M and Promethazine 12.5-25mg I/M DO NOT USE Olanzapine in dementia or Haloperidol for Lewy Body Dementia Cardiac disease or unknown (No ECG) SWITCH Olanzapine 2.5 5mg IM Page 21 of 52

Notes: a. Evidence i. The best evidence for benefit over risk of harm is for IM lorazepam used alone and the combination of IM haloperidol plus an IM promethazine. ii. When IM haloperidol is combined with IM promethazine there is some suggestion that risk of movement-related side effects may be reduced. iii. In contrast, the combination of an IM benzodiazepine plus IM haloperidol does not appear to be more effective than an IM benzodiazepine used alone. iv. While IM haloperidol used alone is more effective than placebo, it clearly carries greater risk of extrapyramidal and other side effects when compared with placebo or an IM benzodiazepine. b. Choice depends on current treatment. i. If patient is established on antipsychotics, lorazepam may be used alone. ii. If the patient uses street drugs or already receives regular benzodiazepines, an antipsychotic may be used alone. c. Ensure procyclidine injection is available. Antipsychotics may cause acute dystonic reaction. d. Ensure flumazenil injection is available to reverse effects of lorazepam injection. e. The maximum dose of olanzapine is 20mg/24 hours by any (combined) route(s) this should not be exceeded without obtaining specialist advice and not more than 3 I/M doses may be given in any 24-hour period. Wait 2 hours between doses. f. Intramuscular olanzapine and intramuscular lorazepam must not be administered within 1 hour of each other. g. Olanzapine IM needs to be diluted before administration in 2.1ml water for injection. It is stable for up to 1 hour after reconstitution. The following table provides injection volumes for delivering various doses of olanzapine: Dose (mg) Volume of Injection (ml) 5.0 1.0 7.5 1.5 10 2.0 h. Lorazepam should be mixed 1:1 with water for injection before injecting. The following table provides injection volumes for delivering various doses of lorazepam once diluted. Dose of lorazepam Volume of undiluted Volume of WFI Required lorazepam (4mg/mL) 0.5 0.125mL 0.125mL 1.0 0.25mL 0.25mL 2.0 0.5mL 0.5mL i. The maximum daily dose of haloperidol is either 20mg orally or 12mg by intramuscular injection. Maximum doses will need to be adjusted if a combination of both routes is used. The bioavailable equivalence of haloperidol being approximately 10mg oral: 6mg intramuscular. j. For promethazine, in the elderly, (and in physically debilitated patients and those with impaired renal, hepatic, cardiac or respiratory function), there are no specific dose recommendations but lower doses should be considered and particular caution should be exercised in patients with a diagnosis of dementia. Page 22 of 52

Algorithm 3. Rapid Tranquillization of the Acutely Disturbed / Violent Patient Children and Adolescents Aged 6 to 17 Years Step 1 Step 2 Oral Treatment (If oral is refused con sider going to step 3) [a,b] NON - PHARMACOLOGICAL MEASURES De -escalation, distraction, seclusion etc Olanzapine <12 years: N/A >12 years: 5mg (Max. 20mg/day) ` PSYCHOTIC ILLNESS +/ - Promethazine <12 ye ars: 5-10mg (Max 25mg/day) >12 years: 10-25mg (Max 50mg/day) OR Consult any Advance Decisions Check Consent has been given Lorazepam <12 years: 0.5-1mg >12 years: 1-2mg (Max. 4mg/day) Lorazepam <12 years: 0.5-1mg >12 years: 1-2mg (Max 4mg/day) NON-PSYCHOTIC ILLNESS OR Promethazine <12 years: 5-10mg (Max 25mg/day) >12 years: 10-25mg (Max 50mg/day) - ALLOW AT LEAST ONE HOUR FOR ORAL MEDICATION TO WORK - IF INEFFECTIVE, REPEAT ORAL MEDICATION AT SAME DOSES - ALLOW AT LEAST ONE HOUR FOR REPEATED ORAL MEDICATION TO WORK Step 3 I/M Treatment MONITOR PATIENT CLOSELY! [c,d] Ensure baseline measurements are recorded where possible: TEMPERATURE, PULSE, BP, RESPIRATORY RATE before IM administration, and repeat every 5-10 minutes for 1 hour, then half hourly - until patient is ambulatory. If patient refuses, record whatever is possible. Use pulse oximetry if patient asleep or unconscious. Olanz apine [e,f] <12 years: N/A >12 years: 5mg (Max. 20mg/day) Promethazine [g] <12 years: 5-10mg (Max 25mg/day) >12 years: 10-25mg (Max 50mg/day) +/ - OR Lorazepam <12 years: 0.5-1mg >12 years: 1-2mg (Max. 4mg/day) Lorazepam <12 years: 0.5-1mg >12 years: 1-2mg (Max 4mg/day) [g] OR Promethazine <12 years: 5-10mg (Max 25mg/day) >12 years: 10-25mg (Max 50mg/day) 1. ALLOW AT LEAST 30 MINUTES FOR I/M LORAZEPAM TO WORK. IF INEFFECTIVE, REPEAT AT SAME DOSES AND ALLOW A FURTHER 30 MINUTES FOR EFFECT. 2. A REPEAT DOSE OF I/M OLANZAPINE MAY BE GIVEN BUT NOT WITHIN. TWO HOURS OF THE FIRST. Caution See note [e]. DO NOT PROCEED FURTHER WITHOUT ADVICE FROM CONSULTANT IF INEFFECTIVE, SEEK SPECIALIST ADVICE FROM CONSULTANT NB,Max doses stated are for oral and IM combined. [a- g] see notes. Page 23 of 52

Notes: a. Evidence i. The best evidence for benefit over risk of harm is for IM lorazepam used alone and the combination of IM haloperidol plus an IM promethazine. ii. When IM haloperidol is combined with IM promethazine there is some suggestion that risk of movement-related side effects may be reduced. iii. In contrast, the combination of an IM benzodiazepine plus IM haloperidol does not appear to be more effective than an IM benzodiazepine used alone. iv. While IM haloperidol used alone is more effective than placebo, it clearly carries greater risk of extrapyramidal and other side effects when compared with placebo or an IM benzodiazepine. b. Choice depends on current treatment. i. If patient is established on antipsychotics, lorazepam may be used alone. ii. If the patient uses street drugs or already receives regular benzodiazepines, an antipsychotic may be used alone. c. Ensure procyclidine injection is available. Antipsychotics may cause acute dystonic reaction. d. Ensure flumazenil injection is available to reverse effects of lorazepam injection. e. The maximum dose of olanzapine is 20mg/24 hours by any (combined) route(s) this should not be exceeded without obtaining specialist advice and not more than 3 I/M doses may be given in any 24-hour period. Wait 2 hours between doses. f. Intramuscular olanzapine and intramuscular lorazepam must not be administered within 1 hour of each other. g. Olanzapine IM needs to be diluted before administration in 2.1ml water for injection. It is stable for up to 1 hour after reconstitution. The following table provides injection volumes for delivering various doses of olanzapine: Dose (mg) Volume of Injection (ml) 5.0 1.0 7.5 1.5 10 2.0 h. Lorazepam should be mixed 1:1 with water for injection before injecting. The following table provides injection volumes for delivering various doses of lorazepam once diluted. Dose of lorazepam Volume of undiluted Volume of WFI Required lorazepam (4mg/mL) 0.5 0.125mL 0.125mL 1.0 0.25mL 0.25mL 2.0 0.5mL 0.5mL i. The maximum daily dose of haloperidol is either 20mg orally or 12mg by intramuscular injection. Maximum doses will need to be adjusted if a combination of both routes is used. The bioavailable equivalence of haloperidol being approximately 10mg oral: 6mg intramuscular. j. In children and adolescents, younger than 12 years of age the recommended dose of promethazine is 5-10mg (max 25mg/day). In those older than 12 years of age the recommended dose is 10-25mg (max 50mg/day). The product must not be used in children under 2 years of age Page 24 of 52

Algorithm 4. Rapid Tranquillization of the Acutely Disturbed / Violent Patient Learning Disabilities PRIOR TO RAPID TRANQUILLIZATION Try non-pharmacological measures - De-escalation, distraction, etc. Always offer oral medication before IM. If patient refuses or oral is ineffective then consider IM RT. o Lorazepam 1-2mg o OR haloperidol 2.5-5mg with promethazine 25-50mg o OR olanzapine 2.5-5mg Allow at least one hour for oral medication to work. Consult any Advance decision/statements KNOWN PATIENT MONITORING Ensure baseline measurements are recorded where possible: Record pulse, blood pressure, respiration rate, temperature, level of hydration and level of consciousness EVERY 30 minutes (15 minutes if extra risk - see below) for at least 2 hours EXTRA RISKS INCLUDE If the BNF maximum dose has been exceeded Or the service user: o appears to be asleep or sedated o has taken illicit drugs or alcohol o has a pre-existing physical health problem o has experienced any harm as a result of any restrictive intervention. UNKNOWN OR NEUROLEPTIC NAÏVE PATIENT No cardiac disease (ECG carried out) Haloperidol 2.5-5mg I/M and Promethazine 25mg-50mg I/M (a.1) WAIT 30 minutes Cardiac disease or unknown (No ECG) Lorazepam 1-2mg I/M Or Olanzapine 2.5-5mg IM WAIT 30 minutes Partial response REPEAT Lorazepam 1-2mg I/M Lorazepam 1-2mg (a 1.) I/M WAIT 30 minutes No response Partial response No response Partial response No response REPEAT Haloperidol 2.5-5mg I/M and Promethazine 25-50mg I/M SWITCH Lorazepam 1-2mg I/M Or (WAIT 1hr) (f) Olanzapine 2.5-5mg IM REPEAT Lorazepam 1-2mg I/M Or (WAIT 2 Hours) (e) Olanzapine 2.5-5mg IM SWITCH Lorazepam 1-2mg I/M Or Olanzapine 2.5-5mg I/M (WAIT 1 hour) (f) No cardiac disease (ECG carried out) Haloperidol 2.5-5mg I/M and Promethazine 25-50mg I/M Cardiac disease or unknown (No ECG) Olanzapine 2.5-5mg IM (WAIT 1 hour) (f) Page 25 of 52

Notes: a. Evidence i. The best evidence for benefit over risk of harm is for IM lorazepam used alone and the combination of IM haloperidol plus an IM promethazine. ii. When IM haloperidol is combined with IM promethazine there is some suggestion that risk of movement-related side effects may be reduced. iii. In contrast, the combination of an IM benzodiazepine plus IM haloperidol does not appear to be more effective than an IM benzodiazepine used alone. iv. While IM haloperidol used alone is more effective than placebo, it clearly carries greater risk of extrapyramidal and other side effects when compared with placebo or an IM benzodiazepine. b. Choice depends on current treatment. i. If patient is established on antipsychotics, lorazepam may be used alone. ii. If the patient uses street drugs or already receives regular benzodiazepines, an antipsychotic may be used alone. c. Ensure procyclidine injection is available. Antipsychotics may cause acute dystonic reaction. d. Ensure flumazenil injection is available to reverse effects of lorazepam injection. e. The maximum dose of olanzapine is 20mg/24 hours by any (combined) route(s) this should not be exceeded without obtaining specialist advice and not more than 3 I/M doses may be given in any 24-hour period. Wait 2 hours between doses. f. Intramuscular olanzapine, intramuscular lorazepam or intramuscular promethazine must not be administered within 1 hour of each other. g. Olanzapine IM needs to be diluted before administration in 2.1ml water for injection. It is stable for up to 1 hour after reconstitution. The following table provides injection volumes for delivering various doses of olanzapine Dose (mg) Volume of Injection (ml) 5.0 1.0 7.5 1.5 10 2.0 h. Lorazepam should be mixed 1:1 with water for injection before injecting. The following table provides injection volumes for delivering various doses of lorazepam once diluted. Dose of lorazepam Volume of undiluted Volume of WFI Required lorazepam (4mg/mL) 0.5 0.125mL 0.125mL 1.0 0.25mL 0.25mL 2.0 0.5mL 0.5mL i. The maximum daily dose of haloperidol is either 20mg orally or 12mg by intramuscular injection. Maximum doses will need to be adjusted if a combination of both routes is used. The bioavailable equivalence of haloperidol being approximately 10mg oral: 6mg intramuscular. j. For promethazine, in LDS, (and in physically debilitated patients and those with impaired renal, hepatic, cardiac or respiratory function), there are no specific dose recommendations but lower doses should be considered. The lower dose should normally be used initially and titrated upwards according to response if necessary. Repeat doses should not be considered within an hour of a previous dose and a maximum dose of 100mg in 24 hours should not be exceeded. Doses of up to 150mg have been used but this would be unlicensed use. Page 26 of 52

10 Specialist Advice for Working Outside the Appropriate Algorithm (NB. Recommended adult doses are quoted. Doses will usually be lower in the elderly, those with a learning disability and in children and young people). 10.1 Advice must be sought from the consultant or appropriate specialist, at any stage of RT if any doubt exists regarding how best to proceed or if the treatment algorithms have been followed and there is no improvement. 10.2 Physical illness should be re-investigated. 10.3 The following treatments are rarely used, have a minimal evidence base and are unlicensed. They may only be prescribed by a consultant psychiatrist or appropriate specialist who has previous experience of their use. Any decision to use these treatments must only be taken when more conventional treatments have failed and the reason for use must be fully documented in the patient s notes. The advice below relates to use in adults. 10.3.1 Levomepromazine 12.5-50mg IM is highly sedative. Avoid in adults over 50 years due to significant hypotensive effects. Avoid in children and adolescents. 10.3.2 Aripiprazole 9.75mg IM can be considered however NICE did not recommend its use due to lack of evidence of efficacy in rapid tranquilization compared to the recommended agents. Aripiprazole is less hypotensive and sedative than olanzapine, and may be considered on these grounds. 10.3.3 Normally, Clopixol Acuphase (zuclopenthixol acetate) should never be considered as a first-line drug for Rapid Tranquillization as its onset of action will often not be rapid enough in these circumstances. In addition, the administration of an oil-based injection carries very high risk in a highly agitated patient. It should not be used antipsychotic naïve patients.. It should only be used in situations where patients refuse oral medication and require frequent IM injections Clopixol Acuphase (zuclopenthixol acetate) could be considered as an option when it is recognised that the patient will be disturbed/violent over an extended time period and has a past history of a good / timely response. Some patients may want Acuphase included in advance directions or statements. http://www.sussexpartnership.nhs.uk/node/1465/attachment 10.3.4 IM midazolam can no longer be considered due to the relatively high risk of respiratory depression with this product. Further to this, and in response to the Department of Health s Never Events List 2012/13 (published January 2012), the Trust Drugs & Therapeutics Group took the decision in January 2013 that this product would no longer be made available to Trust units. 10.4 If prescribing more than one antipsychotic or prescribing in excess of maximum doses, (see Appendix 6), an ECG should be carried out to exclude arrhythmias. 10.5 Emergency ECT may also be considered but only by a specialist. Page 27 of 52

11 Intravenous Therapy. 11.1 The intravenous administration of benzodiazepines or haloperidol should not normally be used other than in very exceptional circumstances, which should be specified and recorded. This decision should only be taken by a consultant or appropriate specialist who has previous experience of using intravenous interventions. Administration may only be undertaken by a practitioner who is fully trained in IV administration. 11.2 If immediate tranquillization is essential then intravenous administration may be considered necessary. If so, it is essential that attending staff have been appropriately trained to recognise symptoms of respiratory depression, acute dystonia and cardiovascular compromise. 11.3 If intravenous medication is used, the patient must be subject to within eyesight observation. Intravenous administration must not take place without full access to support and resuscitation services. (See Trust Resuscitation Policy). 12 Responsibilities. Healthcare organisations have an obligation to ensure treatments are safe and effective and that the NICE guidelines have been taken into account. They should ensure their staff receive appropriate training. This section aims to help staff understand their responsibilities and accountabilities, it is not exhaustive and professionals must also consider their own Codes of Practice. 12.1 The Trust: Will ensure that Governance arrangements are in place and will include audit procedures that relate to training needs and provision, and the review of untoward incidents. Will ensure that that the policy is reviewed and updated to support Governance arrangements. Will ensure that the policy is current and based on national guidance. Will learn and react appropriately to any untoward incidents and events related to RT. Will respond or react to any resource implications related to RT. 12.2 Medical and Nursing Professional Leads: Will provide or facilitate the provision of training required to support the clinical principles of this policy. 12.3 Trust Pharmacy Team: Will provide a brief update on RT as part of the Medicines Management essential training day for qualified nursing staff which will include signposting to the e-learning module and any recent updates. Page 28 of 52

Will offer advice with regard to the content of more comprehensive training and with regard to any changes of policy or guidance that may be needed due to amended national guidance on the use of RT medication. Will support the maintenance of updating the e-learning module with regard to any changes made in the RT Policy. 12.4 Ward Managers and Modern Matrons: Will understand the policy requirements as it relates to their areas of service and be responsible for the implementation of the policy within their scope of management. Will identify and support the RT training needs of their nursing staff through preceptorship and supervision programs, staff appraisal and the PDP process, and will reflect these in service training plans. Will identify and manage service needs in relation to training, skill mix and staff availability to ensure safe procedures for RT at all times. Will ensure that all registered nurses working in inpatient units and PICUs receive RT training or updates at least every two years. Will ensure that RT medication and other associated medication is available and regularly checked to ensure nothing is missing and nothing is due to expire. Will ensure supportive measures are available to all staff following an RT incident and will ensure that time is made available for reflection and exploration of learning points. 12.5 Consultants: Will understand the policy requirements as it relates to their areas of service and be responsible for the implementation of the policy within their scope of management. Will liaise with local tutors to identify and support the RT training needs of their junior grade doctors through training programs, supervision, appraisal and the PDP process, and will reflect these in staff training plans. 12.6 Individual Clinical Staff: Will read and understand the policy and guidance. Will complete and pass e-learning module. Will identify their own training needs in relation to RT through the appraisal process, with reference to the Trust essential training policy. Will only carry out RT procedures that they have been trained and assessed as competent to do. 13 Monitoring Compliance with the Policy. The Drugs and Therapeutics Group will ensure that audits are carried out against the standards set by this policy and guidance. Page 29 of 52

In conjunction with the audit feedback, this policy will be reviewed at least bi-annually to embed any identified improvements, changes in legislation or best practice. The review will be undertaken by the Chief Pharmacist (Governance & Professional Practice) and will be supported by the Executive Sponsor. The assistance of the Clinical Audit department will be sought for specific audits. This policy will be updated on a regular basis to ensure that it continues to reflect national guidance and the NHSLA Risk Management Standards. 14 Development, consultation and ratification. This Trustwide policy and guidance was originally developed by the Trust pharmacy team in 2008. Wide consultation and development involved the following forums and individuals. A pro-forma was issued to capture feedback. Trust Drugs & Therapeutics Group Trust Pharmacy Forum Trust Health and Safety Committee Trust Associate Directors of Nursing The policy was originally ratified by the Trust Professional Practice Forum (PPF) in October 2008. At this point the policy did not cover the use of Rapid Tranquillization in Child and Adolescent Services. In 2009 the policy was extended to cover the use of Rapid Tranquillization in CAMHS. This work was undertaken by the Trust s specialist clinical pharmacist for CAMHS in liaison with CAMHS consultants. The extension to the policy was approved by the Drugs & Therapeutics Group in October 2009. The policy received further review with regard to patient monitoring procedures and staff group responsibilities, by a working group of consultants, senior nurses and pharmacists between November 2010 and March 2011. Amendments were approved by the Drugs & Therapeutics Group in April 2011. The policy was further reviewed in April 2016 following the publication of NICE guidelines NG10. 15 Dissemination and Implementation of policy. Following ratification of this policy the Executive Sponsor will ensure the document is forwarded to the Health & Social Care Governance Support Team who will allocate an official document number and log the document on the Trust central database The HSCG Support Team will inform the sponsor and document authors of the official document number allocated. The Chief Pharmacists will ensure that the policy is posted on the Trust website and that further staff notification occurs via the D&T Newsletter. Further dissemination will be agreed between the authors and the Executive Sponsor and compliance against specified training will be monitored through the audit process. 16 Document Control including Archive Arrangements. The Health & Social Care Governance Support Team will maintain an archive of previous versions of the policy and will update the central database and website. Archived documents Page 30 of 52

will be listed on the database, with details of the date they were archived and removed from the website and a link to the superseding document if appropriate. Requests from staff to access archived procedural documents can made to the Health & Social Care Governance Support Team (for all documents dated April 2006 onwards). Requests from other organisations or individuals outside of the Trust must be made in accordance with the Freedom of Information Act. 17 References 1. Violence and aggression the short-term management in mental health, health and community setting. National Institute for Clinical Excellence, May 2015. 2. Violence the short-term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments. National Institute for Clinical Excellence, February 2005. 3. Prescribing Guidelines in Psychiatry 12 th Edition, 2015. The South London and Maudsley NHS Trust and Oxleas NHS Trust. 4. Paton C. (2002) benzodiazepines and disinhibition: a review. Psychiatric Bulletin; 26: 460-462. 5. Summaries of Product Characteristics. www.medicines.org.uk (Association of the British Pharmaceutical Industry). 6. Taylor D, Paton C, Kerwin R. The South London and Maudsley & Oxleas NHS Foundation Trusts Prescribing Guidelines, 12th edition. Wiley-Blackwell. 2015. 7. CredibleMeds website (Drug Lists by Group) www.azcert.org/medical-pros/druglists/drug-lists.cfm (accessed 11.3.13) 8. NHS Greater Glasgow and Clyde Medicines Information Services. Drug Induced QT Prolongation. PostScriptExtra (Dec 2012) Issue 21 www.ggcprescribing.org.uk/media/uploads/ps_extra/pse_21.pdf 9. Citrome L. Lurasidone for schizophrenia : a review of the efficacy and safety profile for this newly approved second-generation antipsychotic Int.Journal of Clinical Practice (2011) 65 (2) 189-210 10. Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges NG11. National Institute for Clinical Excellence, May 2015. 11. The Frith Prescribing Guidelines for adults with an intellectual disability. HealthComm UK. 2008. 12. Mental Health Act 1983 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/435512/ MHA_Code_of_Practice.PDF 18 Other Trust Policies to be Cross-referenced This protocol should be read and used in conjunction with the following Trust policies and documents. Violence And Aggression (PMVA) The Prevention And Management Of Policy http://policies.sussexpartnership.nhs.uk/clinical-3/423-violence-and-aggression-pmvathe-prevention-and-management-of-policy Essential Training Policy http://policies.sussexpartnership.nhs.uk/workforce/essentialtraining-policy Resuscitation and Anaphylaxis Policy http://policies.sussexpartnership.nhs.uk/clinical- 3/resuscitation-and-anaphylaxis-policy Page 31 of 52

Resuscitation & Basic Life Support with Defibrillation Essential Training Schedule (accessed via My Learning ) Rapid Tranquillization e-learning module (accessed via My Learning ) Medicines Management Update for Qualified Nurses - Training Schedule (accessed via My Learning ) Observation Policy http://policies.sussexpartnership.nhs.uk/clinical-3/461-observationpolicy Seclusion and Long Term Segregation Policy http://policies.sussexpartnership.nhs.uk/clinical-3/468-new-seclusion-long-termsegregation-policy-and-procedure Advance Decisions and Advance Statements Policy http://policies.sussexpartnership.nhs.uk/clinical-3/422-advance-decisions-and-advancestatements-policy Preceptorship Policy http://policies.sussexpartnership.nhs.uk/workforce/443- preceptorship-policy Guidelines for the administration of Long Acting Injections in Adults http://www.sussexpartnership.nhs.uk/node/1493/attachment Page 32 of 52

Appendix 1 Physical health monitoring and remedial measures (6) Rapid Tranquillization monitoring If possible, after any parenteral drug administration, monitor the following: Temperature Pulse Blood Pressure Hydration Level of Conciousness Respiratory Rate Every 30 minutes (15minutes in at risk patients), for at least two hours, then half-hourly until there are no further concerns about physical health status. If the patient is asleep or unconscious, the use of pulse oximetry to continuously measure oxygen saturation is desirable. The patient must remain under within eyesight observation at least until they are fully ambulatory again. ECG and haematological monitoring are also strongly recommended when parenteral antipsychotics are given, especially when higher doses are used. Hypokalaemia, stress, and agitation place the patient at risk of cardiac arrhythmias. Remedial measures in rapid tranquillization Get urgent medical assistance if not already present: Problem Acute dystonia (including oculogyric crises) Remedial measures Give procyclidine 5 10mg IM Reduced respiratory rate Give oxygen; raise legs; ensure patient is not (<10/min) or oxygen saturation lying face down. (<90%) Give flumazenil if benzodiazepine-induced respiratory depression suspected (see Appendix 2). If induced by any other sedative agent, ventilate mechanically. Irregular or slow (<50/min) pulse Fall in blood pressure (>30mmHg orthostatic drop or <50mmHg diastolic) Refer to specialist medical care immediately. Lie patient flat, tilt bed towards head. Monitor closely. Increased temperature Withhold antipsychotics (risk of NMS and perhaps arrhythmias). Check creatinine kinase urgently. Page 33 of 52

Conscious Level Respirations (12-20) Pulse (51-100) If patient is ambulatory and stable (total scores of 0 or 1) consider discontinuing observations. Concious Level SPO₂ SPO₂ Respiratory Rate Pulse SYSTOLIC Blood Pressure (100-139) Diastolic (Blood Pressure) (60-89) Temperature (36.1-37.4 C) Temperature Rapid Tranquillization Policy Appendix 2A RAPID TRANQUILLIZATION PHYSICAL OBSERVATION CHART - IM MEDICATION Patient name DATE TIME (24 hour) Observations (minutes) 40 39 38.5 38 37.5 37 36 35 34 Temperature 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 Systolic BP Diastolic BP 140 > 130 120 110 100 90 80 70 60 50 40 Pulse 30 21-29 17-20 12-16 10-11 9 8 Respirations 97-100 94-96 93 Oxygen Saturation Awake and active Awake and calm Asleep but rousable Asleep and U nresp o nsive Conscious Level Hydrated-Yes(0)or No(2) TOTAL MEWS Initials Time monitoring initiated: Ward Date of birth Time monitoring stopped: 0 30 60 90 120 150 180 210 240 270 300 330 360 390 420 3 40 3 3 39 3 3 38.5 3 3 38 3 2 37.5 2 0 37 0 0 36 0 1 35 1 3 34 3 Temperature 3 200 3 2 190 3 2 180 3 2 170 3 1 160 3 1 150 3 1 140 3 0 130 3 0 120 3 0 110 3 0 100 3 1 90 2 1 80 0 3 70 0 3 60 0 3 50 2 3 40 3 Systolic BP Diastolic BP 3 140 3 3 130 3 3 120 3 2 110 2 1 100 1 0 90 0 0 80 0 0 70 0 0 60 0 1 50 1 3 40 3 Pulse 3 30 3 2 21-29 2 0 17-20 0 0 12-16 0 1 10-11 1 2 9 2 3 8 3 Respirations 0 97-100 0 0 94-96 0 3 93 3 MEWS Oxygen Saturation A 0 A 0 R 2 U 3 Conscious Level Hydrated TOTAL MEWS Initials Page 34 of 52

Instructions Ensure oral medication for the treatment of acute agitation has been considered and found to be ineffective or inappropriate before prescribing IM. Use this chart to record patient monitoring undertaken during a single episode of intramuscular (IM) RT. If patient consents to physical examinations, ALL observations on this chart should be recorded. If patient refuses observations, record as R. Respiration rate and consciousness should still be recorded. Signs of dehydration include, dry mouth, UTIs, poor skin condition or reduced quantity of liquids consumed. Monitor at least every 30 minutes (every 15 minutes for at risk patients on AT RISK chart). Continue monitoring for a minimum of 120 minutes and longer if the patient remains unstable. At risk patients include:- The BNF maximum dose has been exceeded The service user o Appears to be asleep or sedated o Has taken illicit drugs or alcohol o Has a pre-existing physical health problem o Has experienced any harm as a result of any restrictive intervention Page 35 of 52

Conscious Level Concious Level SPO₂ SPO₂ Respirations (12-20) Respiratory Rate Pulse (51-100) SYSTOLIC Blood Pressure (100-139) Temperature (36.1-37.4 C) If patient is ambulatory and stable (total scores of 0 or 1) consider discontinuing observations. Pulse Diastolic (Blood Pressure) (60-89) Temperature Rapid Tranquillization Policy DATE Temperature Systolic BP Diastolic BP Pulse 9 8 Respirations 94-96 93 Oxygen Saturation Appendix 2B 40 39 38.5 38 34 140 > 130 120 110 90 80 70 AT RISK PATIENTS (Please see instructions on back) RAPID TRANQUILLIZATION PHYSICAL OBSERVATION CHART - IM MEDICATION Patient name Ward Date of birth TIME (24 hour) Observations (minutes) 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 37.5 37 36 35 100 60 50 40 30 21-29 17-20 12-16 10-11 97-100 Awake and active Awake and calm Asleep but rousable Asleep and U nresp o nsive Conscious Level TOTAL MEWS Initial Time monitoring initiated: Time monitoring stopped: 0 15 30 45 60 75 90 105 120 135 150 165 180 195 210 3 40 3 3 39 3 3 38.5 3 3 38 3 2 37.5 2 0 37 0 0 36 0 1 35 1 3 34 3 Temperature 3 200 3 2 190 3 2 180 3 2 170 3 1 160 3 1 150 3 1 140 3 0 130 3 0 120 3 0 110 3 0 100 3 1 90 2 1 80 0 3 70 0 3 60 0 3 50 2 3 40 3 Systolic BP Diastolic BP 3 140 3 3 130 3 3 120 3 2 110 2 1 100 1 0 90 0 0 80 0 0 70 0 0 60 0 1 50 1 3 40 3 3 30 3 2 21-29 2 0 17-20 0 0 12-16 0 1 10-11 1 2 9 2 3 8 3 Respirations 0 97-100 0 0 94-96 0 3 93 3 MEWS Pulse Oxygen Saturation A 0 A 0 R 2 U 3 Conscious Level TOTAL MEWS Initial Page 36 of 52

Instructions Ensure oral medication for the treatment of acute agitation has been considered and found to be ineffective or inappropriate before prescribing IM. Use this chart to record patient monitoring undertaken during a single episode of intramuscular (IM) RT. If patient consents to physical examinations, ALL observations on this chart should be recorded. If patient refuses observations, record as R. Respiration rate and consciousness should still be recorded. Monitor at least every 15 minutes. Continue monitoring for a minimum of 120 minutes and longer if the patient remains unstable. At risk patients include:- The BNF maximum dose has been exceeded The service user o Appears to be asleep or sedated o Has taken illicit drugs or alcohol o Has a pre-existing physical health problem o Has experienced any harm as a result of any restrictive intervention Page 37 of 52

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